Basic Information
| Provider Information | |||||||||
| NPI: | 1164048492 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 867 | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845010867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 4356372377 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 S 600 E | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845013174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377289 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2020 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLSON | ||||||||
| AuthorizedOfficialFirstName: | JEANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4356377200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH INC | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.